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Addition of Magnetic Resonance Imaging to Computed Tomography and Sensitivity to Blood in Pituitary Apoplexy

Eoin P. Flanagan, MB, Bch; Andrea Leep Hunderfund, MD; Caterina Giannini, MD; Irene Meissner, MD
Arch Neurol. 2011;68(10):1336-1337. doi:10.1001/archneurol.2011.247.
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A 63-year-old man presented after being awoken by a severe headache followed by vomiting. Initial neurologic examination was nonlateralizing and showed mild drowsiness. Computed tomography (CT) of the head performed 10 hours after symptom onset revealed a suprasellar mass (Figure 1A). Magnetic resonance imaging (MRI) was performed 24 hours after CT and demonstrated blood in the mass consistent with pituitary apoplexy (Figure 1B and C). Subsequent examinations revealed bitemporal hemianopia confirmed by formal perimetry (Figure 2). Before this presentation, the patient had no symptoms attributable to the pituitary mass. Laboratory testing revealed panhypopituitarism. Hydrocortisone and thyroxine administration was commenced, and transsphenoidal resection of the pituitary was performed. The pathologic examination revealed extensive necrosis consistent with an acutely infarcted pituitary adenoma (Figure 3). By 6 weeks after surgery, the patients' visual field deficit completely resolved, and 1 year later no evidence of residual tumor was seen on repeated neuroimaging. However, persistent pituitary failure required long-term hormone treatment.

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Figure 1. Neuroimaging, perimetry, and pathologic findings in pituitary apoplexy. A, Computed tomography of the head demonstrating a 13-mm soft-tissue prominence in the suprasellar cistern (arrows). Magnetic resonance images of the head (despite movement artifact) demonstrating hyperintensity in the pituitary sella on axial fluid-attenuated inversion recovery sequence (arrows) (B) and sagittal T1-weighted (arrows) (C) images consistent with acute to subacute blood products from pituitary apoplexy.

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Figure 2. Perimetry demonstrating bitemporal hemianopia.

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Figure 3. Hematoxylin-eosin section illustrating complete necrosis of the pituitary tissue in which the “ghosts” of the adenoma cells are recognizable with a pink homogeneous cytoplasm and a slightly darker central or eccentric nucleus. The sheetlike pattern of the cells is consistent with an acutely infarcted pituitary adenoma rather than an infarcted normal anterior pituitary in which typically the normal “nested” architecture of pituitary lobules is maintained. Scattered vessels filled with red blood cells are noted.




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